The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize ATLANTIC PHYSICAL THERAPY or insurance company to release any information required to process my claims.

Patient/ Guardian signature Date

ASSIGNMENT OF BENEFITS

Date:

Patient:

Employer:

Claim Group:

SS#/ID#:

I hereby instruct and direct Insurance Company to pay by check made out and mailed to:

Atlantic Physical Therapy

736 Arthur Godfrey Rd.

Miami Beach, FL 33140

If my current policy prohibits direct payment to doctor, I hereby also instruct and direct you to make out the check to me and mail it as follows:

Atlantic Physical Therapy

736 Arthur Godfrey Rd.

Miami Beach, FL 33140

For the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS DIRECT ASSIGNMENT OF YM RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjustor, or attorney involved in this case.

I authorize the therapist to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

I understand and agree that health insurance policies are an arrangement between an insurance company and myself. Furthermore, I understand that Atlantic Physical Therapy will prepare any necessary reports and forms to assist me in collecting from my insurance company, and that any amount authorized to be paid to Atlantic Physical Therapy, Inc., will be credited towards my account upon receipt. However, I clearly understand and agree that All Services Rendered Me Are Charged Directly To Me And That I Am Personally Responsible For Payment, including payment of any applicable insurance deductible and/or insurance co-payments. I also understand that if I suspend or terminate my care and treatment prior to the doctor releasing or discharging me from care, any fees for professional services rendered to me will be immediately due and payable.

Patient’s Signature:X Date: Witness:

Authorization To Release Medical Information:

I authorize the release of any medical information necessary to process my insurance claim(s). I also certify that all insurance information given to this healthcare provider is correct and complete.

Patient’s Signature:X Date:Witness:

Consent For Physician To Proceed With Treatment:

I, accept out-patient physical therapy treatment by Atlantic Physical Therapy Inc. according to the company policies and procedures, as requested by my attending physician. I hereby, authorize Atlantic Physical Therapy, Inc. to administer therapeutic procedures as may be reasonably ordered by my physician and or medically necessitated by my illness, injury or condition. This treatment and care has been explained to me and I fully understand the above permission. This consent is intended as a waiver of liability for such treatment and care except in documented instances of negligence. I have received and understand the patient Bill of Rights.

Patient Bill of Rights

(Medicare Patients Only)

You have the right to receive all the hospital care that is necessary for the proper diagnosis and treatment of your illness or injury. According to Federal law, your discharge date must be determined solely by your medical needs, not by Medicare payments. You have the right to be fully informed about decisions affecting your Medicare coverage and payment for your hospital stay and for post-hospital services. You have the right to request a review by Medicare Peer review Organization (PRO) of any written Notice of Non-coverage that you receive from the hospital or HMO stating that Medicare will no longer pay for your hospital care. You have the right to question or place a complaint about the quality of care you have received as either a Medicare recipient or a member of a Medicare HMO.
Patient’s Signature: X Date: Witness:

Authorization To Release Healthcare/Medical Records:

I, hereby authorize any person to whom this authorization is presented, either in person, by mail, by fax or otherwise; to furnish Atlantic Physical Therapy/Daniel Iannettone, D.P.T.; ANY AND ALL MEDICAL RECORDS, MEDICAL REPORTS, X-RAYS OR OTHER DIAGNOSTIC TEST REPORTS & FILMS concerning my present or past health condition/injury or general health status.
Patient’s Signature: X Date: Witness:

Patient Acknowledgment

I understand the services that are/will be provided and the anticipated frequency and duration of the visits/treatment. I am a participant in my care plan. Understand the goals of care, and assist with the development of the plan. I am to be informed of any changes concerning aspects of my condition related to my care. I have received a copy and understand that IF I HAVE ANY QUESTIONS, CONCERNS or COMPLAINTS I AM TO CALL THE BUSINESS OFFICE MANAGER. The office hours are Monday through Friday 9:00 am to 5:00 pm. I will receive a response no later than 24 hours of my inquiry. All complaints will be investigated and be kept confidential. I understand as reviewed with me my eligibility for MEDICAID/MEDICARE or PRIVATE INSURANCE and my financial liability when applicable. If my financial liability changes, Atlantic Physical Therapy will notify me in writing within 5 working days prior to change. I understand the charges for my care, if any and accept responsibility for the charges. I understand as reviewed with me the anticipated goals for services/ therapy. I understand as reviewed with me the discharge planning. I understand as reviewed with me that I am to keep the appropriate forms in my home for future reference.

Patient’s Signature: X Date: Witness:

INFORMATION ON PAIN

Dear Patients

As a concerned member of the medical community, I’m aware of your disabilities and resulting pain. However, many times during the rehab process, your pain may get worse before it gets better. This occurs because, in most instances, we are eliminating the pain and not just temporarily relieving it. For example: if you’re treated on a Monday and your pain worsens, this is normal. However, by Wednesday or Thursday your pain should be significantly less overall. This process will repeat itself several times, gradually getting better until your pain is gone. So please, be patient and see your progress from week to week, not day by day.

Yourconcernedtherapist,
Dan

ATTENTION PATIENTS

Please take note of the following rules and regulations of our office:

All patients are required to keep their scheduled appointments in a timely manner. Atlantic Physical Therapy reserves the right to discharge patients who do not observe this policy.
All Copays and Deductible payments must be paid before patients begin treatment.

Most importantly,

NO CELL PHONES IN THE TREATMENT AREA, PLEASE!

These policies are enforced so you receive the best treatment each and every visit.
Thank you!